Why Alzheimer's Patients Behave the Way They Do

by Harry S. Lipscomb, M.D, F.A.C.P. Professor of Family and Community
Medicine Texas A & M University College of Medicine Family
members of Alzheimer's patients often say to me, "We just
can't understand why she acts so normal sometimes and then can be
so difficult at others." Or more often they ask, "Why
does he ask the same questions or do the same things over and
over? Why does he constantly touch things or wander
aimlessly?" The answer to these questions lies in a study of
how you learn and how you forget.

The
Remembering and Learning Processes

To remember events that have occurred in your life, your brain requires that these
events be so vivid that you reflect on them afterward. Consider
how you learn a language or a mathematical formula: you repeat it
until it becomes second nature to you. And if your teaching is
inadequate (or your teachers unmemorable), it's likely that it
lacked the vividness to attract either your attention or your
memory. Also consider the really important events in your life:
accidents, first love, or first school triumph or disaster. Each
of these events was characterized by a "memorable" sort
of afterglow because you endow them with vividness. I don't
remember my first cut (or stitches afterwards), but I will always
remember my first love, simply because I attached such
world-shaking importance to the event. As you reflect on these
things (perhaps many times as you grow older) the memories become
essentially shadows of the event. Moreover, you derive from the
event a whole set of secondary emotional feelings: pleasure,
sadness, anger, nostalgia, affections, excitement, etc. These
events (and the emotions they arouse) become stored in special
areas of the brain for deeply embedded information, commonly
called long-term memory. If your special brain areas for deeply
embedded information remain basically intact (as they seem to do
in those with Alzheimer's), you can recall not only these
memories but also your emotional responses to them. It may take a
little longer for older persons to resurrect the memory, but if
they are allowed to ruminate a bit, the memory comes to the
surface. Equally important is that these skills, events, and
learned things are resurrected often as we mature and they are
referred to often. This is the way you learn from experience. For
example, it doesn't take many burns for a child to learn not only
about fire but about heat. Of course, in early life, most of the
warm things were pleasant. Perhaps the hardest part of learning
for the child is to distinguish the difference between good heat
and bad heat. This is the first difference in the memory
disturbance of dementia. Ask a demented person who still has
language skills something about his younger years, such as,
"Do you remember when you had your first party dress or your
father had a buggy?" it will surprise you that these
deeply-buried experiences are vividly recalled. A lot of brain
energy went into the storage of these experiences. So most
persons with dementia have a rather good long-term memory of
their early life.

Effects of
Alzheimer's

Alzheimer's patients have lost the ability to recognize current life events
with vividness. They cannot learn new things because they cannot
reflect upon them. If they learn to make a stitch or throw a ball
on Monday, they cannot remember how to duplicate the task on
Tuesday. Everything is new and there is nothing left for
reflection, storage, or recall. We deem this to represent loss of
short-term memory. Even when you penetrate what seems to be a
grim apathy in these persons, Alzheimer's patients can never
again endow an event with vividness so that they'll remember it.
For example, Alzheimer's patients seem to know warm from cold,
but they seem to have lost their ability to resurrect from deep
memory any useful, newly learned information. They will remember
their first burn, but they won't be able to remember that the
bathtub today (like yesterday) has hot water in it. This
explanation of short-term and long-term memory is a simplified
version of a complex process. There are many other things
involved in this process. Alzheimer's patients not only cannot
endow vividness to events but cannot reflect upon these events
and learn something new. Your efforts to teach, retrain, or
enable Alzheimer's patients to do for themselves are most often
fruitless. This is not to say that you shouldn't try, but only up
to your limit of frustration.

Caregiving
Techniques

In dealing with family caregivers, one of my hardest tasks is to show them how to
handle those behaviors that reflect this loss of vividness and
learning capacity. If a loved one has died and the loss is no
longer vivid, Alzheimer's patients will not remember it. Thus,
they will call, endlessly, for a departed spouse. I see families
attempting to impose reality with phrases such as, "Mamma,
you know Papa Tom's been dead for 10 years." These
delusional thoughts (mostly over money, infidelity, or jewelry)
also may exhaust unimaginative caregivers. When a loved one
insists that someone is under the bed, it is fruitless to attempt
to argue with them. A perceptive daughter told me she had stopped
saying, "Mamma, I've looked under the bed and no one's
there" and replaced her answer with, "What color hair
does he have?" Her mother then will give her a long and
detailed description. Basically, what I'm saying is that not only
have these persons lost the ability to reflect and learn, but in
their world there is no reality (as we know it) and no such thing
as truth or falsehood. This means it's all right for caregivers
to fib and fabricate and to deflect, deceive, or distract these
folks. This notion was brought home to me most poignantly by a
woman whose 7-year-old son asked, "Mamma, why do you lie to
Grandmama?" The mother replied, "It's easier on her and
all of us." Lying is very hard for most of us who have spent
our lives insisting on the truth. But Alzheimer's patients live
in another world. They remember the "long time ago."
live only in today, and cannot plan a future. Caregivers may find
it painful, but they must enter this other world to make their
life easier and to make life more comfortable for their loved
one.